How We Get Labeled

Par

don the personal question, but have you ever had a sexual fantasy involving the use of a nonliving object — Anna Kournikova's tennis outfit, say, or Tom Cruise's Risky Business skivvies? Actually, don't answer that — we really don't want to know — and you should probably think twice before telling your therapist. She might diagnose you with fetishism, which is listed along with schizophrenia and bipolar disorder in a curious but extremely influential book called the Diagnostic and Statistical Manual of Mental Disorders, or DSM for short.

The DSM lists the criteria used by mental-health professionals to make their various diagnoses, from "mild mental retardation" (the first listing) to "personality disorder not otherwise specified" (the last); there are more than 350 in all. Hence this 943-page doorstop is one of the most important books you've never heard of. And the inscrutable process of writing it is starting up again. The American Psychiatric Association (A.P.A.), the manual's publisher, recently began planning a giant review of the book. The new edition, the fifth — called DSM V — will appear around 2010. Evidently, it takes a long time to figure out all the ways America is nuts.

LATEST COVER STORY Mind & Body Happiness Jan. 17, 2004 Past Issues Tsunami Jan. 10, 2004 ----------------- Person of the Year Jan. 3, 2004 ----------------- Secrets of the Nativity Dec. 13, 2004 ----------------- The Stealth Killer Dec. 6, 2004 ----------------- Coolest Inventions Nov. 29, 2004 ----------------- Battle for Fallujah Nov. 22, 2004 ----------------- Four More Years Nov. 15, 2004 ----------------- The Joy Of Sox Nov. 8, 2004 ----------------- The Morning After Nov. 1, 2004 ----------------- The God Gene Oct. 25, 2004 ----------------- The Vote Battle Oct. 18, 2004 ----------------- Visions of Tomorrow Oct. 11, 2004 ----------------- The Tragedy of Sudan Oct. 4, 2004 ----------------- CBS Controversy Sept. 27, 2004 ----------------- America's Border Sept. 20, 2004 ----------------- Struggle Within Islam Sept. 13, 2004 ----------------- World of George Bush Sept. 6, 2004 -----------------   SPECIAL REPORTS  Coolest Video Games 2004  Coolest Inventions  Wireless Society  Cool Tech 2004 PHOTOS AND GRAPHICS  At The Epicenter  Paths to Pleasure  Quotes of the Week  This Week's Gadget  Cartoons of the Week More graphics >> More photos >> MORE STORIES Advisor: Rove Warrior The Bushes: Family Dynasty Klein: Benneton Ad Presidency More Stories >> CNN.com: Latest News

The first official attempt to measure the prevalence of mental illness in the U.S. came in 1840, when the Census included a question on "idiocy/insanity." From that single category flowered many more disorders, but each asylum classified them differently. The DSM was first published in 1952 so that "stress reaction" would mean the same in an Arkansas hospital as it does in a Vermont one.

The DSM works like this: imagine you are Tony Soprano in the first season of The Sopranos. You have, in DSM-ese, "recurrent, unexpected panic attacks." You also have "persistent concern about having additional attacks," and you fear you're "losing control, having a heart attack, 'going crazy.'" You aren't on drugs (other than all those bottles of Vesuvio's wine), so — presto — Dr. Melfi gives you a diagnosis of panic disorder, DSM No. 300.01. By the way, if you truly think you are Tony Soprano, see No. 295, schizophrenia.

Of course, in the real world, psychiatric diagnosis doesn't — or at least shouldn't — work like a checklist at a sushi counter. Many of the items that appear as diagnostic criteria in the DSM are sometimes symptoms of a disorder and sometimes signs of perfectly normal behavior. An adolescent who "often argues with adults" may have an unusual condition called "oppositional defiant disorder" or a more common condition called "being 14 years old." The DSM includes a cautionary statement saying it takes clinical training to tell the difference. But many nonspecialists use the book too: insurers open the DSM when disputes arise over the proper course of treatment for particular conditions. (If your treatment doesn't jibe with the DSM, you may not get reimbursed.) DSM diagnoses can be used by courts to lock you in a mental hospital or by schools to place your child in special-education classes. A DSM label can become a stigma.

All of which raises a pressing question: What actually goes into defining a disorder? A.P.A. officials take this question seriously, and they understand the high stakes of a DSM diagnosis. That's one reason they so often revise the book to keep it current with the latest research. (Three editions have been published since 1986.) According to Dr. Darrel Regier, chief of A.P.A. research, roughly 1,000 mental-health professionals will help produce DSM V. The A.P.A. will host at least a dozen conferences, review unending piles of literature and conduct new studies to see whether proposed changes would work in clinical settings.

But like the conditions it helps diagnose, the DSM is more than the sum of its symptoms. As the American storehouse of insanity — the dictionary of everything we consider mentally unbalanced — it's a window into the national psyche. And so it bears close reading, and close questioning, by those outside the psychiatric establishment. Why is caffeine intoxication included as a disorder when sex addiction isn't? Why is pathological gambling apparently crazy when compulsive shopping isn't?

More important, can even a thousand Ph.D.s gathered at a dozen conferences ever really know the significance of such vague symptoms as "fatigue," "low self-esteem" and "feelings of hopelessness"? (You need only two of those, along with a couple of friends telling the doctor you seem depressed, to be a good candidate for something called dysthymic disorder.) Though it's fashionable these days to think of psychiatry as just another arm of medicine, there is no biological test for any of these disorders. While imaging techniques have shown abnormalities in the brain of some people with schizophrenia, no scan can diagnose even that severe condition, let alone something opaque like "histrionic personality disorder." (For which the DSM lists the following as a sign: "consistently uses physical appearance to draw attention to self." So I'm sick if I exchange my Aunt Thelma's drab sweaters for flashier ones every Christmas?)